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We have a 79 yr old patient who has endocarditis, recent hip replacement, on hospice at home for end stage cardiac disease (refuses valve replacement). She has had a right mastectomy with node removal. She requires 6 weeks of IV Rocephin. IR placed a left picc, which they were unable to thread to the SVC because of occlusion to the inominate. They left it in place. The nurses were unable to obtain a blood return-she was sent back to IR-they "opened" the PICC up yesterday. According to the IR note the subclavian and the inominate are now occluded-but this is still "an adequate central line" according to the radiologist. Her left arm is swollen today (was not yesterday), and the nurses cannot get a blood return.

Obviously this line needs to be removed. What options do we have for 6 weeks of IV abx? Hickman? Or a right PICC?

Sounds like a right PICC is all that is left. Has the extremity ever had edema? In my previous practice, my team used mastectomy sides several times successfully. THe first one was the chairman of anesthesiology's wife and it was upon his suggestion.

I also like the idea of a permentent line in the right. The physician may not want to do that thought, because of the diagnosis of endocarditis (bacteremia). I have had endocarditis patients out of no where develop a raging bacteremia during their treatment. Good luck!

Your IR is mistaken. This line was never an "adequate central line". It was always a midclavicular line, which is known to have a greater rate of thrombosis. In this case, it may have originally been the best choice but that has changed due to the complication of what sounds like vein thrombosis - no real surprise. In most situations with mastectomy and these catheter-related complications, a tunneled catheter would probably be the best. In my opinion, the issue would be whether this patient could tolerate a transfer to a hospital and the minor surgical procedure for insertion of a tunneled catheter. I would want to know her history of any edema in the right arm and her preferences for treatment. Is she alert and oriented and capable of making her own decisions? At this point in her life, I would allow her to have the final say in which catheter she has inserted.

I think this patient described above is a candidate for a mediport with access in the Right Mid Bicep Basilic vein. I am hypothesizing that this would reduce venous infection due to lymph node removal somewhat, as long as the accessing technique is STRICT sterile and well protected. If I understand correctly, this patient will have ongoing needs for IV therapy till end of life.